Provider Demographics
NPI:1134111529
Name:HAVASU PHYSICAL THERAPY
Entity Type:Organization
Organization Name:HAVASU PHYSICAL THERAPY
Other - Org Name:DONNA G JONES D/B/A HAVASU PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / SOLE PROPRIETOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:GALE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:928-854-7676
Mailing Address - Street 1:2126 MCCULLOCH BLVD N
Mailing Address - Street 2:STE 18
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6742
Mailing Address - Country:US
Mailing Address - Phone:928-854-7676
Mailing Address - Fax:928-854-7676
Practice Address - Street 1:2126 MCCULLOCH BLVD N
Practice Address - Street 2:STE 18
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6742
Practice Address - Country:US
Practice Address - Phone:928-854-7676
Practice Address - Fax:928-854-7676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2169225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2169OtherAZ BOARD OF PT EXAMINERS
CA5372OtherPT BOARD OF CA
67557Medicare ID - Type Unspecified